CASE CONCEPTUALIZATION

Client Name

Presenting Concern: Why did the client come to counseling?

Case Conceptualization: Note: Include specific information about client symptoms and presenting concerns. Include demographic information. Review biopsychosocial factors and considerations including: biology, family, culture, environment, and other relevant systemic considerations; assess how the addiction impacts all major life areas.

Assessment: Identify and describe 1–2 assessment tools to be used with this client and the rationale for selecting the assessment tool.

Diagnostic Impressions: Note: Include the provisional diagnosis for the client and any rule-out or alternative considerations noted.

Rationale for Diagnostic Impressions: Note: Use the DSM-5 to explain how the client’s symptoms are reflected in the diagnostic criteria for each diagnosis that you render.

Therapeutic Approach: Identify the chosen therapeutic approach to be used with this client and the rationale for your selection.

Treatment Goals: Identify three initial treatment goals you are considering in working with this client and note how you will measure/know when goals are attained. Note: Significant issues will need treatment goals.

Relapse Prevention and Continuum of Care: Describe relapse prevention needs and challenges for the client. Discuss the continuum of care plan and recommendations for the client.

Ethical Considerations: Note any ethical considerations or challenges associated with this case.